Percutaneous direct carotid puncture using an elastic needle for coil embolization of a ruptured cerebral aneurysm with right-sided aortic arch and carotid stenosis: illustrative case

Abstract

BACKGROUND

Endovascular treatment of ruptured intracranial aneurysms can be particularly challenging in patients with a right-sided aortic arch and concomitant carotid artery stenosis, where stable catheterization via conventional transfemoral routes is often impossible. Direct carotid puncture is a potential alternative. However, conventional sheaths can transiently occlude the carotid artery and increase the risk of cerebral ischemia.

OBSERVATIONS

An 87-year-old patient with subarachnoid hemorrhage due to a ruptured intracranial aneurysm presented with a right-sided aortic arch and severe calcified stenosis of the left common carotid artery. Given the tortuous and stenotic vascular anatomy, transfemoral access was discontinued. Percutaneous direct carotid puncture of the left common carotid artery was performed using an elastic needle with an outer diameter of 1.7 mm. This low-profile access allows microcatheter navigation and successful coil embolization without perioperative ischemic or hemorrhagic complications. Hemostasis was achieved using simple manual compression.

LESSONS

When conventional endovascular access is precluded by complex vascular anatomy, particularly in cases complicated by carotid artery stenosis, direct carotid puncture using an elastic needle may offer a safer and less invasive alternative. This approach provides a feasible option in anatomically challenging situations in which standard sheaths would increase the risk of ischemic complications.

https://thejns.org/doi/10.3171/CASE25869

The right-sided aortic arch is a rare congenital vascular anomaly, reported in approximately 0.1% of imaging studies, and is classified based on the course of the esophagus and the origin of the left subclavian artery.^1,2 Neuroendovascular therapy through this anatomical variant can be challenging because steep angulation and low vessel origin hinder catheter introduction, necessitating alternative access routes.³ Furthermore, when carotid artery stenosis coexists, the difficulty is compounded, as vascular access through conventional transfemoral or transbrachial routes may be impossible, and direct carotid puncture carries the risk of carotid occlusion or ischemic complications.

A patient presented with a right-sided aortic arch and severely calcified carotid stenosis, for whom standard endovascular access was not feasible. To minimize the risk of carotid occlusion and access site bleeding, coil embolization was performed via direct percutaneous carotid puncture using an elastic needle. This case illustrates the technical feasibility of this low-profile device and highlights its potential as a safer and less invasive alternative for anatomically complex cases.

Illustrative Case

This 87-year-old woman had histories of hypertension, diabetes mellitus, hyperlipidemia, bronchial asthma, hepatocellular carcinoma, and angina pectoris. She was admitted to the hospital for severe disturbance of consciousness. On arrival, her Glasgow Coma Scale (GCS) score was 5 (E1, V1, M3), and she had anisocoria (right, 2 mm; left, 4 mm). Her blood pressure was 206/157 mm Hg. Tracheal intubation was performed immediately because of respiratory compromise. CT revealed a diffuse subarachnoid hemorrhage (SAH) with posterior brainstem displacement (Fig. 1A). CT angiography (CTA) revealed bilateral internal carotid artery (ICA) aneurysms (Fig. 1B): a 6-mm right ICA–posterior communicating artery aneurysm and a 10.8-mm left ICA–anterior choroidal artery (ICA-AChrA) aneurysm. Because the patient had World Federation of Neurosurgical Societies grade V SAH, the initial management was conservative due to the patient’s age and comorbidities.

FIG. 1.

A: CT scan showing diffuse SAH with posterior displacement of the brainstem. B: CT angiogram showing bilateral ICA aneurysms (arrows). C: CT scan obtained the following day, revealing a washout of the hematoma in the basal cistern and residual hematoma in the posterior region of the left ICA, suggesting that the left ICA-AChrA aneurysm was the source of bleeding (arrow). D: The left ICA-AChrA aneurysm was an elongated aneurysm with a maximum diameter of 10.8 mm.

However, the next morning, the patient’s consciousness significantly improved to a GCS score of E4, VT, and M5, and anisocoria resolved. Repeat CT suggested that the left ICA-AChrA aneurysm was the source of bleeding, as the hematoma in the left carotid cistern persisted despite washout in the basal cistern (Fig. 1C). No external ventricular drainage or surgical CSF diversion was performed during the acute phase, as the patient was initially managed conservatively. Given the dramatic neurological improvement, the patient underwent coil embolization of the left IC-AChr aneurysm on day 3 to prevent rerupture.

The left ICA-AChrA aneurysm was elongated, with a maximum diameter of 10.8 mm and a bleb suggestive of rupture (Fig. 1D). Crucially, CTA revealed severe and complex access challenges: a right-sided aortic arch with a low-origin left common carotid artery (CCA), a Kommerell diverticulum at the left subclavian artery origin (Fig. 2A), and most critically, severe circumferential calcified stenosis of the left CCA bifurcation, leaving a lumen of only 2.2 mm (Fig. 2B and C). Because of this severe tortuosity and narrow calcified lumen, stable seating of a conventional guide catheter or distal access catheter via the transfemoral route was anticipated to be highly difficult.

FIG. 2.

A: CT angiogram revealing a right-sided aortic arch, with the left CCA branching from the lowest point (arrow), with a Kommerell diverticulum at the origin of the left subclavian artery (arrow). B and C: Stenosis of the left cervical carotid artery bifurcation is evident, with circumferential calcification and a lumen of 2.2 mm.

Under general anesthesia, a transfemoral approach was attempted using an 8-Fr guiding system (8-Fr long sheath and 8-Fr FUBUKI XF, ASAHI Intec Co., Ltd.) with a 6-Fr Simmons catheter (Medikit Co., Ltd.). As predicted, the system was volatile and slipped repeatedly due to the challenging aortic arch anatomy and severe left cervical stenosis, which prevented stable access to the left ICA (Fig. 3A). Therefore, the transfemoral approach was abandoned, and percutaneous direct puncture of the left CCA was selected as the most feasible alternative. Other potential approaches, such as transradial or transbrachial access, were considered less desirable, given the complexity of navigating the right-sided arch and the potential for a less direct trajectory through the tortuous aortic segments.

FIG. 3.

A: An 8-Fr FUBUKI XF 90-cm guiding system and 6-Fr Simmons catheter slip easily because of severe vascular access due to a right-sided aortic arch and stenosis of the left cervical carotid artery. B: Elastic needle used for direct carotid puncture. Upper: Elastic needle in its assembled state, consisting of a metal inner needle and a flexible PTFE outer sheath. Lower: Photograph showing the elastic needle after removal of the metal inner needle, leaving only the flexible PTFE outer sheath that remains within the artery during the endovascular procedure. C:The left CCA was punctured percutaneously using a 19-gauge elastase puncture needle, and a guidewire and the outer sheath of elastic needle were inserted into the ICA under roadmap guidance. D: A Y-connector was attached to the hub of the outer sheath, and continuous pressurized flushing with heparinized saline was maintained to prevent thrombus formation.

Percutaneous direct puncture was performed using a 19-gauge elastic needle with an outer diameter of 1.7 mm (Hakko Co., Ltd.), and the guidewire and outer sheath were inserted under roadmap guidance (Fig. 3B and C). Once arterial access was obtained, a Y-connector was attached to the hub of the elastic needle, and continuous pressurized flushing with heparinized saline was maintained throughout the procedure to prevent thrombus formation (Fig. 3D). The small profile of this specialized needle was specifically chosen to minimize flow obstruction through the severely stenotic segment during the procedure and to reduce potential damage to the calcified vessel wall. A microcatheter (Excelsior SL-10, Stryker) was successfully navigated through the outer sheath into the ICA and advanced into the aneurysm. We administered an initial intravenous bolus of 3000 units of heparin, followed by 1000 units per hour. The activated clotting time was maintained between 200 and 250 seconds throughout the procedure. Coil embolization was successfully performed, and complete occlusion of the aneurysm was confirmed using digital subtraction angiography (DSA) (Fig. 4). At the end of the session, the heparin was allowed to reverse naturally before manual compression for hemostasis. After needle removal, hemostasis was easily achieved with manual compression and natural heparin reversal, minimizing postprocedural risks at the puncture site.

FIG. 4.

A and B: Eleven coils were used in the embolization procedure. Disappearance of the aneurysm was confirmed on DSA (arrows).

Extubation was performed the next day without any new neurological deficits. Although the patient experienced systemic complications, such as aspiration pneumonia, urinary infection, and hematochezia, no cerebral vasospasm was observed. On day 73 after onset, the patient was transferred to a rehabilitation hospital with a modified Rankin Scale score of 4. Follow-up imaging confirmed stable coil occlusion of the aneurysm and, importantly, no evidence of pseudoaneurysm, dissection, or restenosis at the left CCA puncture site.

Informed Consent

The necessary informed consent was obtained in this study.

Discussion

Observations

A right-sided aortic arch is a rare congenital anomaly resulting from the persistence of the right fourth aortic arch and right dorsal aorta during embryogenesis.¹ In cases in which there is a retroesophageal aortic segment, as in the present case, the origins of the carotid and subclavian arteries are low-lying with acute takeoff angles, making endovascular procedures technically challenging.^2–6 The difficulty is further compounded by concomitant cervical carotid artery stenosis, which limits the feasibility of conventional transfemoral or transbrachial approaches and increases the risk of cerebral ischemia during catheter manipulation.

Rationale for Direct Carotid Access

In anatomically complex cases, a direct percutaneous carotid puncture can provide an alternative access route. Previous reports have described its use with 4- to 6-Fr sheaths for thrombectomy, carotid stenting, and flow diverter placement.^7–11 However, conventional sheaths may transiently occlude the carotid artery, especially in stenotic vessels, thereby increasing the risk of cerebral ischemia.

In the present case, although the angiographic image (Fig. 3C) might suggest a navigable lumen, CTA revealed circumferential, heavy calcification with a diameter of 2.2 mm. A standard 6-Fr guiding catheter typically has an outer diameter of approximately 2.1 mm. Navigating a 6-Fr guide through a 2.2-mm calcified, noncompliant stenosis may carry a high risk of iatrogenic vessel dissection or plaque rupture and total occlusion of the lumen, which could cause acute cerebral ischemia during the procedure. By using the 19-gauge elastic needle (outer diameter 1.7 mm), we ensured a sufficient “safety margin” within the 2.2-mm lumen, maintaining distal perfusion while providing a stable platform for coiling.

Advantages of the Elastic Needle

The elastic needle is an indwelling needle consisting of a metal inner needle and a flexible polytetrafluoroethylene (PTFE) outer sheath. It is commonly used for arterial and venous access and is characterized by a thin wall and a low outer profile, allowing relatively high flow despite its small diameter. A 19-gauge elastic needle with a low-profile outer diameter of 1.7 mm was used, offering 3 key advantages: 1) reduced risk of carotid occlusion and ischemia during the procedure; 2) facilitation of microcatheter navigation without passing through a challenging access route; and 3) easy hemostasis at the puncture site by manual compression, minimizing bleeding complications.

Technical Pearls for Direct Carotid Puncture

Based on our experience, we suggest the following technical pearls to enhance the safety of direct carotid artery puncture:

1. Ultrasound access. While roadmap guidance was used in this specific case, we agree that ultrasound is the gold standard for avoiding internal jugular vein injury and selecting a plaque-free puncture site.

2. Guidewire selection under fluoroscopy. We recommend using a hydrophilic guidewire to advance the elastic needle’s outer sheath into the ICA under fluoroscopic guidance, thereby minimizing the risk of vessel dissection.

Limitations and Patient Selection

This approach has inherent limitations. Only a single microcatheter can be introduced through the outer sheath, precluding the use of adjunctive devices such as balloons in the event of intraprocedural rupture. Bleeding complications remain a potential concern, particularly in patients receiving thrombolytic or dual antiplatelet therapies.^7,12 Careful patient selection, minimal device use, and sheath removal after anticoagulation therapy reversal are essential to ensure safety.

In summary, direct carotid puncture with an elastic needle may be a helpful alternative when conventional endovascular access is unfeasible. Despite technical limitations, this technique may allow safe coil embolization even in anatomically challenging cases such as those with a right-sided aortic arch and carotid artery stenosis.

Lessons

Direct carotid puncture with an elastic needle can provide a feasible and safe alternative for coil embolization in cases in which conventional endovascular access is precluded by a complex vascular anatomy, such as a right-sided aortic arch combined with carotid artery stenosis. Although this approach has inherent technical limitations and potential risks, careful patient selection and perioperative management might help maximize safety and expand its role as a valuable treatment option in challenging scenarios.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Maeda, Ohbayashi, Nabika. Drafting the article: Maeda, Ohbayashi. Critically revising the article: Yasuoka. Reviewed submitted version of manuscript: Yasuoka. Approved the final version of the manuscript on behalf of all authors: Maeda. Study supervision: Horie.

Correspondence

Yugo Maeda: Matsue Red Cross Hospital, Matsue, Shimane, Japan. ygmaeda3072@gmail.com.